StrokeConnect Follow Up

What is StrokeConnect Follow Up?

StrokeConnect Follow Up is delivered by the Stroke Foundation. Consumers receive a call from a health professional after hospital discharge and are provided with information, advice, support and referral to assist them to better manage their health and stroke recovery.

What do patients receive?

Consumers receive a letter introducing the service two weeks after discharge, and a phone call from a health professional six weeks after discharge. During the call, we:

Enquire about the consumer’s situation, needs and preferences

Screen for common problems, as well as for risk and complexity

Provide education about stroke impacts and secondary prevention

Match information products, resources, services and support groups to their needs and preferences

Discuss a plan for actions to be undertaken following the call.

During the call, the health professional and consumer determine the need for, and timing of, a second call. Consumers are provided with written or web-based information, based on their needs. After the service concludes, the consumer’s GP receives a letter summarising the service delivered.

Who delivers the Follow Up service?

The Stroke Foundation employs allied health and nursing staff with experience in stroke to deliver services to consumers.

How will patients be referred?

Patients are referred as part of preparing for hospital discharge. We will work with participating hospitals to develop referral processes. Information needed for referral will be simple and not onerous to collect. Patients will be provided with written information about the program to ensure informed consent.

Is Follow Up currently delivered in other states?

The Follow Up service has been delivered in Queensland since 2011, thanks to the support of Queensland Health. Follow Up will also be delivered in NSW in 2016, thanks to the support of the nib foundation.

How is Follow Up being implemented in Victoria?

The Stroke Foundation has received funding from the Ian Rollo Currie Foundation to develop and deliver the Follow Up service in Victoria. The service commenced in March 2016 in metropolitan Melbourne, and aims to assist 1500 consumers in the first year. Rural and regional health services are now being invited to participate. We will deliver a service to 6000 consumers during the period from March 2016 to July 2018 and will be seeking support to make the service sustainable after the period of support ends.

Who is eligible?

All stroke survivors and carers over the age of 18 years, who are discharging home or to residential care for the first time are eligible.

Can the Follow Up service meet the needs of diverse populations?

The Follow Up service will aim to meet the unique needs of each stroke survivors and carer, as well as meeting the needs of a diverse community.

Staff will assess people’s communication, language and cultural needs, and will develop strategies to respond to their particular needs. Interpreters will be used when required.

Is the service free?

Yes

Will the program be evaluated?

The impact and outcomes of the service will be evaluated. In 2016, we will focus on understanding consumer satisfaction and short term impact, along with consulting with participating hospitals about whether the service is operating effectively and identifying areas for improvement. In 2017, funding will be sought to begin an outcomes evaluation.